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Lung Cancer Care in Victoria Towards optimal care A/Prof Gavin Wright

Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

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Page 1: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Lung Cancer Care

in Victoria

Towards optimal care

A/Prof Gavin Wright

Page 2: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Data analysis:

CCV / DHHS

Ella Stuart

Dr Luc te Marvelde

Lung Cancer 2019 Summit working party

Chairs: A/Prof Gavin Wright Prof David Ball

Members: Dr Andreas Baisch

Mr Andrew Barling

Dr Richard De Boer

Mr David Deutscher

Dr Wasek Faisal

Prof Michael MacManus

Prof Danielle Mazza

A/Prof Paul Mitchell

A/Prof Gary Richardson

A/Prof Jeremy Ruben

A/Prof Rob Stirling

Dr Craig Underhill

Mr Cheng-Hon Yap

Dr Jackie Yoong

Victorian Tumour Summits project team: Mirela Matthews

Amy Sercombe

Rebecca Miller

Claire Porter

2

Aim:

● Discuss variations in care

● Victorian population perspective

● Variations in local approach

Page 3: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

In this presentation

● Incidence and survival

● Lung cancer population at presentation

● Patterns of care & variation across

Victoria:

○ Diagnosis, staging & treatment

planning

○ Treatment

○ Palliative and supportive care

3

Page 4: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Lung Cancer Optimal Care Pathway (OCP)

4

Page 5: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Linked data sources

Data linkage performed by The Centre for Victorian Data Linkage

5

Unlinked data sources

Cancer Services

Performance Indicator (CSPI)

medical record audit 2017

Victorian Lung Cancer

Registry

Page 6: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

● Statewide data - reliable linkage program

● Population level outcomes - offers general indicative patterns

● Limitations:

○ Does not identify out of hospital care

○ Relies on hospital coding

○ Currently lacks specific disease features (e.g. staging)

○ Hume RICS – no surgery or chemotherapy data for

patients treated in Albury (NSW)

Features of the linked data set

6

Page 7: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Integrated Cancer Services & Cancer Centres

7

GRICS

GICS

Page 8: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Incidence, Demographics & Survival

Page 9: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Incidence

Incidence

Mortality

Mortality Male

Female

Trends in incidence and mortality Victoria 1982 - 2016

Source: Victorian Cancer Registry 9

Page 10: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Lung cancer 5-year relative survival is increasing

Source: Victorian Cancer Registry 10

Page 11: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Demographics - linked dataset

*Death Certificate Only (DCO) patients excluded (2008-2012 n = 602; 2013-2016 n = 417)

**Excluding patients with no admissions between 2 years prior and 1 year after diagnosis.

Source: Linked dataset - VCR, VAED 11

Diagnosed 2008 - 2012

N = 12,040*

Diagnosed 2013 - 2016

N = 10,797*

Male, N (%) 7,170 (60%) 6,154 (57%)

Age (median) 72 72

SES quintile 1 (most disadvantaged), N (%) 3,668 (31%) 3,167 (30%)

Ever smoked, N (%)**

(VAED derived, 2 years prior to 1 year after

diagnosis)

9,798 (81%) 8,914 (83%)

No hospital admissions, N (%)

(VAED, 30 days prior to 1 year after dx date)

274 (2%) 171 (2%)

Page 12: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Tumour characteristics – linked dataset

*Excluding patients with no admissions between 30 days prior and 4 months after diagnosis.

Source: Linked dataset - VCR, VAED 12

Diagnosed 2008 - 2012

N = 12,040

Diagnosed 2013 - 2016

N = 10,797

Morphology:

NSCLC

SCLC

Carcinoid

Other

10,509 (87%)

1,296 (11%)

206 (2%)

29 (<1%)

9,412 (87%)

1,122 (10%)

222 (2%)

41 (<1%)

NSCLC cases:

Adenocarcinoma

Squamous cell carcinoma

Large cell carcinoma

Other/NOS

4,343 (41%)

2,131 (20%)

521 (5%)

3,514 (33%)

4,614 (49%)

1,998 (21%)

152 (2%)

2,648 (28%)

NSCLC cases:

Metastatic disease at diagnosis, N (%)*

(VCR and VAED derived, 30 days prior

to 4 months after dx)

4,900 (49%)

4,517 (50%)

Page 13: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

13

Proportion of lung cancer patients who had metastatic disease at diagnosis by ICS (2008 - 2016) (N = 22,837)

Source: Linked dataset - VCR, VAED. *HRICS data limitation. ** Excluding HRICS.

Pearson’s 𝝌²**:

2008-2012 P = 0.017

2013-2016 P = 0.158

*

Page 14: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Absolute survival time by ICS of residence (metro vs regional) and diagnosis year (2008 - 2016) (N = 22,837)

14 Source: Linked dataset - VCR

Logrank test for difference

between metro and regional:

2008-2012 P < 0.001

2013-2016 P = 0.005

2008-2012 Metro

1 year - 43.6% (95% CI 42.5-44.7)

4 year - 19.2% (95% CI 18.3 - 20.1)

2008-2012 Regional

1 year - 40.3% (95% CI 38.9 - 41.9)

4 year - 16.4% (95% CI 15.3 - 17.6)

2013-2016 Metro

1 year - 48.1% (95% CI 47.0-49.3)

4 year - 23.7% (95% CI 22.5 - 24.9)

2013-2016 Regional

1 year - 46.2% (95% CI 44.6 - 47.9)

4 year - 20.8% (95% CI 19.2-22.6)

Page 15: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Tissue Diagnosis

15

Page 16: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Lung cancer with tissue diagnosis by year of diagnosis (2008 - 2016) (N = 22,483)

16

Pearson’s 𝝌²:

P < 0.001

Test of trend:

P < 0.001

Excluding ‘unknown’ (n=354).

Source: Linked dataset - VCR

Page 17: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Lung cancer with tissue diagnosis by age group (2008 - 2016) (N = 22,483)

17 Excluding ‘unknown’ (n=354).

Source: Linked dataset - VCR

Pearson’s 𝝌²:

2008-2012 P <0.001

2013-2016 P <0.001

Page 18: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Age-adjusted tissue diagnosis by ICS of residence (2008 - 2016) (N = 22,483)

18 Adjusted for age. Excluding ‘unknown’ (n=354).

Source: Linked dataset - VCR

2008 - 2012 2013 - 2016

Page 19: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Multidisciplinary Treatment Planning and Discussion

Page 20: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Victorian Lung Cancer MDMs

20

Page 21: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Documented multidisciplinary team meeting in the patient’s central medical record (2017) (N = 324)

21

Source: CSPI medical record audit 2017.Bars represent 95% CI.

Data limitation - The CSPI audit includes 28 public hospitals and 4 private hospitals.*HRICS data limitation.

Lung Cancer

Summit 2014

Victorian average

(2011-2013) = 62%

* P <0.05

** P <0.001

Victorian Lung

Cancer Registry

Average (2016) =

66%

Page 22: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Proportion of patients with documented evidence of communication of initial treatment plan to GP

(2017) (N = 324)

22 Source: CSPI medical record audit 2017; Bars represent 95% CI.

Data limitation - The CSPI audit includes 28 public hospitals and 4 private hospitals.*HRICS data limitation.

Pearson’s 𝝌²:

P < 0.001

*

Page 23: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Timeliness to Treatment

Page 24: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Time from diagnosis to first treatment - surgery for non-metastatic NSCLC (2013 - 2016) (N = 1,846)

24 Major surgery - lobectomy, pneumonectomy and sublobar resection.

Source: Linked dataset - VCR, VAED, VRMDS 2013-2016

Overall 61% (1,129/1,846) of

NSCLC patients underwent surgery

within 14 days of diagnosis.

Variable Level Surgery within

14 days (%) P-value

Patient

Residence >

Treatment

Location

Regional > Regional 51

<0.001 Regional > Metro 60

Metro > Metro 64

Diagnosis Year

2013 57

0.096

(trend)

2014 60

2015 66

2016 61

Page 25: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Surgery for NSCLC – Access and Survival

Page 26: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Adjusted odds of having surgery for non-metastatic NSCLC by ICS of residence (2013 - 2016) (N = 4,816)

26

Model adjusted for age and comorbidities. Bars represent 95% CI.

Surgery (lobectomy, pneumonectomy, sublobar resection) within 6 months of diagnosis.

Source: Linked dataset - VCR, VAED 2013-2016. *HRICS data limitation.

← Less likely More likely →

*

Page 27: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Survival for non-metastatic NSCLC by ICS of residence (2013-2016) (n = 4,816)

27 Adjusted for age, sex, comorbidities and diagnosis year. Bars represent 95% CI. Victorian average = 1.0.

Source: Linked dataset - VCR, VAED.

ICS

of re

sid

ence

Page 28: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Survival for metastatic NSCLC by ICS of residence (2013-2016) (n = 4,596)

28 Adjusted for age, sex, comorbidities and diagnosis year. Bars represent 95% CI. Victorian average = 1.0.

Source: Linked dataset - VCR, VAED.

ICS

of re

sid

en

ce

Page 29: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

29

Surgery (lobectomy, pneumonectomy, sublobar resection) within 6 months of diagnosis.

Model adjusted for age, sex, comorbidities and diagnosis year. Bars represent 95% CI. Victorian average = 1.0.

Source: Linked dataset – VCR, VAED.

Survival for non-metastatic NSCLC by ICS of residence (2013 - 2016)

Surgical patients (n =1,876) Non surgical patients (n =2,940)

← Better survival Poorer survival → ← Better survival Poorer survival →

Page 30: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Non-metastatic NSCLC patient flow for surgery

(2013 - 2016) (N = 1,876)

30

ICS of

residence

ICS of surgery campus

SMICS WCMICS NEMICS GRICS BSWRICS HRICS** LMICS GICS Total

SMICS 434 (87%) 35 (7%) 30 (6%) 2 (0%) 501 (100%)

WCMICS 16 (4%) 305 (78%) 70 (18%) 1 (0%) 1 (0%) 393 (100%)

NEMICS 33 (8%) 78 (20%) 277 (71%) 1 (0%) 389 (100%)

GRICS 58 (42%) 31 (22%) 10 (7%) 39 (28%) 138 (100%)

BSWRICS 2 (2%) 20 (15%) 2 (2%) 108 (81%) 1 (1%) 133 (100%)

HRICS** 3 (2%) 106 (85%) 14 (11%) 2 (2%) 125 (100%)

LMICS 4 (4%) 37 (33%) 15 (13%) 53 (47%) 4 (4%) 113 (100%)

GICS 3 (4%) 26 (31%) 1 (1%) 3 (4%) 1 (1%) 50 (60%) 84 (100%)

Surgery (lobectomy, pneumonectomy, sublobar resection) within 6 months of diagnosis.

Source: Linked dataset - VCR and VAED 2013-2016. *Excluding HRICS **HRICS data limitation

72% of patients had surgery locally* ≤ 9% 50% - 69%

10% - 29% 70% - 89%

30% - 49% ≥90%

Page 31: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

31

Non-metastatic NSCLC lobectomy:pneumonectomy:sublobar resection by ICS of surgery (2013 - 2016) (n = 1,876)

Surgery (lobectomy, pneumonectomy, sublobar resection) within 6 months of diagnosis.

Source: Linked dataset - VCR, VAED 2013-2016

} } * *

*p=0.01

Page 32: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Average annual lung surgery volume in Victorian hospitals (2010/12 and 2016/18 FY) (N = 2,748)

32 Major lung surgery - lobectomy, pneumonectomy and partial resection procedures.Restricted to patients with a lung cancer diagnosis.

Source: VAED 2017/18 (unlinked)

FY 2016/18

FY 2010/12

Page 33: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Treatment - Radiotherapy

Page 34: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Utilisation of radiotherapy (radical and palliative) for lung cancer patients by ICS of residence (2013 - 2016) (N = 10,797)

34 Patient group - non-metastatic & metastatic at diagnosis; all morphologies. Radiotherapy within 1 year of diagnosis. Source: Linked dataset - VCR, VRMDS 2013-2016.

Difference in RT utilisation

compared to state average:

* p<0.05; * * p<0.001

Difference in radical RT

proportion compared to

state average:

# p<0.05; # # p<0.001

Page 35: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Time from diagnosis to first treatment - RT/CRT for non-metastatic NSCLC (2013 - 2016) (N = 807)

35 Radiotherapy with radical intent. Excluding patients treated with SABR.

Source: Linked dataset - VCR, VAED, VRMDS 2013-2016

The median time to starting radical

RT/CRT for non-metastatic NSCLC

patients was 40 days.

Variable Level

Started RT/CRT

within 40 days

(median) (%)

P-value

Patient

Residence >

Treatment

Location

Regional > Regional 39%

<0.001 Regional > Metro 64%

Metro > Metro 54%

Diagnosis

Year

2013 46%

0.215

(trend)

2014 52%

2015 54%

2016 51%

Page 36: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Treatment - Chemotherapy

Page 37: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Utilisation of chemotherapy for metastatic NSCLC patients by ICS of residence (2013 - 2016) (N = 4,596)

37 *HRICS data limitation. Source: Linked dataset - VCR, VAED 2013-2016.

ICS of

residence

Chemotherapy

within 1 year of

diagnosis (%)

NEMICS 45

SMICS 40

WCMICS 38

BSWRICS 40

GRICS 45

HRICS* 36

LMICS 34

GICS 43

Victoria 41

Difference between ICS:

P-value < 0.001

P-value = 0.002 (excluding HRICS)

Adjusted odds of chemotherapy within 1 year of diagnosis

Adjusted for age and comorbidities. Bars represent 95% CI. Victorian average = 1.0.

ICS

of re

sid

ence

Page 38: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Utilisation of chemotherapy for SCLC patients by ICS of residence (2013 - 2016) (N = 1,122)

38 *HRICS data limitation. Source: Linked dataset - VCR, VAED 2013-2016.

Adjusted for age and comorbidities. Bars represent 95% CI. Victorian average = 1.0.

ICS of

residence

Chemotherapy

within 1 year of

diagnosis (%)

NEMICS 74

SMICS 79

WCMICS 76

BSWRICS 73

GRICS 79

HRICS* 59

LMICS 75

GICS 88

Victoria 76

Difference between ICS:

P-value = 0.020

P-value = 0.329 (excluding HRICS)

Adjusted odds of chemotherapy within 1 year of diagnosis

ICS

of re

sid

ence

Page 39: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Supportive Care

Page 40: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Proportion of patients with documented evidence of supportive care screening (2017) (N = 324)

40 Source: CSPI medical record audit 2017; Bars represent 95% CI.

Data limitation - The CSPI audit includes 28 public hospitals and 4 private hospitals. *HRICS data limitation.

Pearson’s 𝝌²:

P < 0.001

*

Page 41: Lung Cancer Care in Victoria - nemics.org.au...Lung Cancer Optimal Care Pathway (OCP) 4 . Linked data sources Data linkage performed by The Centre for Victorian Data Linkage 5 Unlinked

Big thanks for data:

Kathryn Whitfield - DHHS linked data set, CSPI Audit

Victorian Cancer Registry

The Centre for Victorian Data Linkage (CVDL)

A/Prof Rob Stirling - Victorian Lung Cancer Registry

Acknowledgments

Funders of Victorian Tumour Summits:

Victorian Integrated Cancer Services

DHHS Cancer Strategy & Development